Form S-4 - Application For Registration As Dealer - 2011 Page 4
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4SFN 51526 (10-2011)
Page 4 of 4
14. Applicant or registrant consents that notice of any proceeding or order connected with this application or
registration may be effectively given by sending notice to the person below at the address given.
Name
Title or Capacity
Address
City
State
ZIP Code
Signed and sealed this ___________ day of __________________________________, year ____________
Printed Name of Signatory
Corporate Seal
Signature of Person on Behalf of Applicant
(President, Partner, or Proprietor)
Title
ATTEST
(Secretary of Partner)
STATE OF
)
)ss.
COUNTY OF
)
The undersigned, being first duly sworn, deposes and executes the foregoing application for and on behalf of the applicant
named therein; that he is
of the applicant and is fully authorized to execute and file said
application; that he has read said application and knows the contents thereof; and that to the best of his knowledge and belief
the statements made in said application and in any exhibits attached thereto and other information filed therewith, all of which is
made a part thereof, are correct, true and complete. Applicant further represents that to the extent that information previously
submitted is not correct, such information is currently accurate and complete.
Subscribed and sworn before me this __________________ day of _____________________ year ___________
Notary Public
Notarial Seal
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